Oncoplastic Breast Surgery

Better understanding of breast cancer and innovation in its treatment now allow breast surgeons to use of plastic surgical techniques to improve cosmetic outcomes in breast conservation surgery. This is known as oncoplasic breast surgery. The integration of oncoplastic techniques in breast cancer surgery allows extensive resections, increase the rate of breast conservation, and results in favourable aesthetic outcomes.

Oncoplastic breast surgery is a novel surgical approach to the treatment of breast cancer. The word ‘oncoplastic’ is derived from the Greek words ‘onco’ meaning tumour and ‘plastic’ which means to mould. Plastic surgical techniques are employed in order to reshape the remaining breast or reconstruct the breast after appropriate wide excision of the breast cancer. The result is seamless specialist breast cancer surgery in which ablation of the cancer is merged with reconstruction.

The objective of breast conservation surgery is to remove the whole tumour with a clear margin of healthy tissue around it. A conflict exists between a wide enough resection in order to achieve optimal oncological control and not removing so much breast tissue as to leave a deformed or asymmetric breast. Oncoplastic surgery has emerged as a new approach for extending breast conserving surgery possibilities, potentially reducing both mastectomy and resection rates, while avoiding breast deformities.

The ultimate goal is to achieve both oncologic and cosmetic success. These are the major factors one considers before deciding to have breast cancer surgery.

Oncoplastic breast surgery is a relatively new and rapidly growing field of surgery. It is more technically complex and does requires more time to carry out than the traditional breast surgery. A well trained surgeon in this area has the skills to offer all the surgical options without any cosmetic or oncological drawbacks. The size of the tumour in relation to the size of the breast is the most important factor when predicting the potential cosmetic result. The location of the tumour within the breast plays a vital role in aesthetic outcome.

Oncoplastic breast surgery combines the latest plastic surgical techniques with breast surgical oncology. It is a discipline that requires vision, passion, anatomical knowledge, aesthetic and symmetrical understanding and functions of the breast.

Oncoplastic surgery DOES NOT eliminate the role of the plastic surgeon. Many patients may be more suitable for mastectomy and complex breast reconstruction. Close collaboration between the breast surgeon and the plastic surgeon is essential in order to obtain the total removal of the tumour and an aesthetic result that limits psychological trauma to the woman.

Following breast cancer treatment, overall survival is associated with the cosmetic consequences of the breast surgery. The reconstructive plastic surgery aims to improve the appearance of the patient.

Selection of Patients for Oncoplastic Surgery

Smokers, diabetics, obese individuals, and patients with connective tissue disorders are at a higher risk of wound related complications. An ideal patient for breast conserving surgery will have a favourable tumour to breast size ratio and be suitable for conventional forms of wide local excision in which the tumour is excised with an approximately 1 cm margin of surrounding breast tissue. Oncoplastic procedures allow extensive resection of tissue, increasing the possibility of achieving tumour-free margins, without affecting the aesthetic outcome.Comparison studies against traditional breast conserving surgery show nearly a 50% decrease in need for re-excision when oncoplastic surgery is used. In selected cases chemotherapy is given before surgery to shrink the tumour thus making breast conservationpossible.

The reconstruction method to be performed depends on the size and location of the expected tumour resection and an appreciable ratio of breast volume to resection volume.

Techniques of Oncoplastic Surgery

Breast reconstruction following breast-conserving surgery may be carried out using volume replacement or volume displacement techniques.

Volume Displacement Techniques

This technique in the right patient can eliminate the need for complex reconstructive surgeryusing autologous grafts or implants. The purpose is to move the remaining breast tissue to fill the defect resulting from excision of the tumour. Displacement techniques reshape the breast through advancement, rotation or transposition of existing/remaining breast tissueand skin with a resultant decrease in overall breast volumeand the potential need for a simultaneous contralateral reduction to improve symmetry. The drawbacks include flap necrosis, wound failure, and potential cosmetic failure.

The various options of oncoplastic volume displacement include:

Upper pole of breast

Crescent Mastopexy

Batwing Resection

Hemibatwing Resection

Crescent, batwing or hemi-batwing excisions are best suited for lesions in the upper hemisphere (10 o’clock to 2 o’clock going clockwise). The incision permits correction of breast ptosis (sagging breasts) by elevating the nipple areolar complex.

Lower pole of breast

Triangle Incision

Reduction Mammaplasty

Inframammary (does not remove skin)

These incisions are employed to treat lesions in the lower hemisphere of the breast (3 o’clock to 9 o’clock, going clockwise). Large amounts of breast tissue can be removed with excellent cosmetic results and generally widely clear margins.

Any segment of the breast

Radial–ellipse segmentectomy

Circumareolar approach for segmental resection (does not remove skin)

Donut or round block mastopexy

Wise pattern reduction

Volume Replacement Technique

Autologous (patient’s own) tissue is harvested and transferred into the resection defect, replacing the volume of excised breast tissue. As the volume is restored, contralateral surgery is seldom required to achieve symmetry. Your breast and plastic surgeon will work as a team to remove and reconstruct the breast. The reconstruction can take place at the time of tumour removal or at a later date. The major complication includes donor site morbidity.

Examples include TRAM, DIEP, Latissimus dorsi flaps.

The Other Breast:

The contralateral breast may be reconstructed to improve symmetry. This can be achieved simultaneously with the same procedure (single surgery) or as a second surgery. The disadvantages are:

Unknown final pathology and marginal status of the treated breast

Post-surgical radiotherapy may sometimes result in shrinkage or oedema (swelling) of the breast.

Six to twelve months is the ideal time for the breast to heal following surgery and radiotherapy. Therefore in some institutions, symmetrisation of contralateral breast is preferred to delay for a certain period of time.